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Complications of Thyroid Surgery

Article Last Updated: Nov 7, 2007


AUTHOR AND EDITOR INOR!ATION
Author: "ramod # Sharma$ !D$ Consulting Staff, Ear, Nose and Throat Center
ra!od " Shar!a is a !e!#er of the follo$ing !edical societies: A!erican Acade!% of &tolar%ngolog%'(ead
and Nec) Surger%, A!erican College of Surgeons, A!erican (ead and Nec) Societ%, A!erican Lar%ngological
*hinological and &tological Societ%, A!erican +edical Association, A!erican *hinologic Societ%, Societ% of
Universit% &tolar%ngologists'(ead and Nec) Surgeons, and Utah +edical Association
Coauthor,s-: %ucy & 'arr$ !D$ Staff h%sician, .epart!ent of &tolar%ngolog%'(ead and Nec) Surger%,
Universit% of Utah School of +edicine/ Adam D Ru(in$ !D$ Staff h%sician, *esident, .epart!ent of
&tolar%ngolog%'(ead and Nec) Surger%, Universit% of +ichigan +edical Center
Editors: ! A(raham #uria)ose$ !D$ DDS$ RCS$ Chair!an, (ead and Nec) 0nstitute, A!rita 0nstitute of
+edical Sciences/ rancisco Tala*era$ "harmD$ "hD$ Senior har!ac% Editor, e+edicine/ Nader Sadeghi$ !D$
RCS+C,$ Associate rofessor of Surger%, .irector of (ead and Nec) Surger%, .epart!ent of Surger%, .ivision of
&tolar%ngolog%, 1eorge 2ashington Universit%/ Christopher % Slac)$ !D$ &tolar%ngolog%'3acial lastic
Surger%, rivate ractice, Associated Coastal ENT/ +edical .irector, Treasure Coast Sleep .isorders/ Arlen D
!eyers$ !D$ !'A$ rofessor, .epart!ent of &tolar%ngolog%'(ead and Nec) Surger%, Universit% of Colorado
School of +edicine
Author and Editor Disclosure
Synonyms and related )ey-ords. th%roid surger% co!plications, surgical co!plications, postoperative #leeding,
postoperative infection, vocal fold paral%sis, superior lar%ngeal nerve, SLN, recurrent lar%ngeal nerve, *LN,
h%poparath%roidis!, h%pocalce!ia, hungr% #one s%ndro!e, hungr%'#one s%ndro!e, hungr% #one disease, hungr%'
#one disease, calciu! car#onate, vita!in . replace!ent, Chvoste) sign, Chvoste)4s sign, Trousseau4s sign,
Trousseau sign, h%poth%roidis!, th%roto5ic stor!, electro!%ograph%, E+1, parath%roid hor!one, T(,
parathor!one, parath%roid glands
INTRODUCTION
.uring the 6700s, the !ortalit% rate fro! th%roid surger% $as appro5i!atel% 809: +ost deaths $ere caused #%
infection and he!orrhage: Sterile surgical arenas, general anesthesia, and i!proved surgical techni;ues have !ade
death fro! th%roid surger% e5tre!el% rare toda%:
Theodor "ocher, Theodor <illroth, and 2illia! S: (alsted are =ust a fe$ of the na!es inti!atel% associated $ith
the develop!ent and refine!ent of th%roid surger%: Their contri#utions helped to !a)e th%roid surger% less feared
and #etter understood than it once $as:
Although the co!plication rate of th%roid surger% has certainl% decreased, surgeons !ust nevertheless !aintain a
health% respect for the possi#ilit% of co!plications: atients !ust #e appropriatel% and preoperativel% counseled
regarding potential co!plications: All !ust #e $ell a$are of the surgical ris)s the% are underta)ing: <% developing
a thorough understanding of the anato!% and of the $a%s to prevent each co!plication, the surgeon can !ini!i>e
each patient4s ris): The surgeon4s e5perience is a significant contri#utor to various co!plications during th%roid
surger%: At the sa!e ti!e, several reports have pointed out the safet% of th%roid procedures perfor!ed at residenc%'
training centers, $here surgeries are perfor!ed under the supervision of an e5perienced surgeon: <% understanding
the presentation and treat!ent of each co!plication, the surgeon can handle co!plications e5pedientl% and avoid
$orsening conse;uences:
0n general, co!plications of th%roid surger% can #e considered !inor, rare, or !a=or:
!inor complications
Several !inor co!plications !a% result fro! th%roid surger%:
3or e5a!ple, a postoperative sero!a !a% for!: These !a% #e $atched and allo$ed to resor# on their o$n: Large
sero!as !a% #e aspirated under sterile conditions: *epeated aspirations are often necessar%:
oor scar for!ation is another fre;uentl% preventa#le co!plication: Therefore, create as s!all an incision as
reasona#le in a natural s)in crease over the th%roid gland: The surgeon re;uires ade;uate e5posure and should not
da!age the s)in edges $ith e5cessive retraction: The nec) should #e fle5ed to deter!ine the location of the natural
s)in creases:
Rare complications
Case reports of rare co!plications, such as da!age to the s%!pathetic trun), are occasionall% reported: +ost of
these are unco!!on and can usuall% #e avoided if the surgeon has good )no$ledge of the anato!% and sound
operative techni;ue:
!a/or complications
The follo$ing sections discuss !a=or co!plications that !a% #e encountered in the setting of th%roid surger%:
'%EEDIN0
0ntraoperative #leeding stains the tissues and o#scures i!portant structures: +oreover, intraoperative #leeding
increases the ris) of other anato!ic co!plications: .eli#erate dissection and fastidious he!ostasis are essential to
prevent this co!plication:
ostoperative #leeding can #e a devastating co!plication of th%roid surger%: An unrecogni>ed or rapidl% e5panding
he!ato!a can cause air$a% co!pro!ise and asph%5iation: The incidence of he!orrhage after th%roid surger% is
lo$ ,0:?'69-, #ut the surgeon !ust #e a$are of this potentiall% fatal co!plication:
"resentation
atients $ith postoperative #leeding present $ith nec) s$elling, nec) pain, and@or signs and s%!pto!s of air$a%
o#struction ,eg, d%spnea, stridor, h%po5ia-: 0!!ediatel% e5a!ine such patients for evidence of he!ato!a: 0!aging
studies are of no #enefit in this evaluation:
E*aluation
h%sical e5a!ination is the onl% $or)up necessar%: .o not $aste ti!e $ith i!aging studies $hen #leeding is
possi#le: 3i#eroptic lar%ngoscop% does not help in vie$ing the distal air$a%: 0!aging studies such as CT scanning
and ultrasonograph% !a% #e useful in cases of !ild nec) s$elling $ithout air$a% co!pro!ise: The surgeon !ust
carefull% assess the air$a% #efore transferring a patient for radiologic studies:
"re*ention
The prevention of postoperative #leeding depends on good intraoperative he!ostasis: Sound surgical techni;ue is
essential: The th%roid is a highl% vascular organ and #leeds copiousl%: Therefore, ta)e care to avoid trau!ati>ing the
th%roid tissue during the procedure: <efore closing the $ound, irrigate it $ell and address all residual #leeding:
3inall%, avoid the use of nec) dressings: A dressing that covers the $ound !a% !as) he!ato!a for!ation, dela%ing
its recognition should it occur:
Controvers% still surrounds the use of drains after th%roid surger%: The present authors do not advocate the
postoperative use of suction or nonsuction drainage: *esults of several prospective studies have disputed the
usefulness of drains:
Schoretsanitis et al ,6AA7- rando!l% assigned 200 patients undergoing th%roidecto!% into 2 groups:
6
&ne
group received a suction drain at the ti!e of surger%, $hereas the other did not/ he!ato!as occurred in B9 and 79,
respectivel%: T$o ,29- patients $ithout drains and 6 ,69- $ith a drain re;uired e5ploration for vascular ligation:
Neither of these differences $as statisticall% significant: Schoretsanitis et al ,6AA7- also reported that the
postoperative hospitali>ation ti!e $as longer in the patients $ith drains ,?:8 vs 6:C d-, as $as the duration of
postoperative pain:
6
.e#r% et al ,6AAA- prospectivel% evaluated the usefulness of drains after th%roidecto!% in a rando!i>ed trial for
600 patients:
2
3our patients, all of $ho! received drains, developed he!ato!as:
No definitive evidence suggests that drains prevent he!ato!a or sero!a for!ation: 0f a drain is placed, its
use should not su#stitute for intraoperative he!ostasis: Nonsuction drainage is not reco!!ended #ecause it
increases the infection ris) and the need for nec) dressings: These dressings o#struct the vie$ of the nec) and
!a% dela% diagnosis of a he!ato!a:
Treatment
0f a nec) he!ato!a is co!pro!ising the patient4s air$a%, open the surgical incision at the #edside to release the
collection of #lood, and i!!ediatel% transfer the patient to the operating roo!:
0n the case of a he!ato!a $ithout i!pending air$a% o#struction, transfer the patient to the operating roo! as soon
as is practical: *e!ain $ith the patient and #e prepared to assist $ith intu#ation or tracheosto!%:
0n the operating roo!, open the surgical incision, e5plore the $ound, irrigate it, control all #leeding sites, and close
the $ound:
IN&UR1 TO THE RECURRENT %AR1N0EA% NER2E
The recurrent lar%ngeal nerve ,*LN- innervates all of the intrinsic !uscles of the lar%n5 $ith the e5ception of the
cricoth%roid !uscle, $hich is innervated #% the superior lar%ngeal nerve ,SLN-: +echanis!s of in=ur% to the *LN
include co!plete or partial transection, traction, contusion, crush, #urn, !isplaced ligature, and co!pro!ised #lood
suppl%: The conse;uence of an *LN in=ur% is true vocal'fold paresis or paral%sis:
"resentation
atients $ith unilateral vocal fold paral%sis present $ith postoperative hoarseness or #reathiness: The presentation
is often su#acute: At first, the vocal fold usuall% re!ains in the para!edian position, creating a fairl% nor!al voice:
.efinite vocal changes !a% not !anifest for da%s to $ee)s: The paral%>ed vocal fold atrophies, causing the voice to
$orsen: &ther potential se;uelae of unilateral vocal'fold paral%sis are d%sphagia and aspiration:
<ilateral vocal'fold paral%sis !a% occur after total th%roidecto!%, and it usuall% !anifests i!!ediatel% after
e5tu#ation: <oth vocal folds re!ain in the para!edian position, causing partial air$a% o#struction: atients $ith
#ilateral vocal'fold paral%sis !a% present $ith #iphasic stridor, respirator% distress, or #oth: &n occasion, a
patient presents $ith air$a% signs in the i!!ediate postoperative period #ecause the air$a% is sufficient despite the
paral%>ed vocal folds: At follo$'up, such patients !a% present $ith d%spnea or stridor $ith e5ertion:
E*aluation
Techni;ues for assessing vocal fold !o#ilit% include indirect and fi#eroptic lar%ngoscop%: .ocu!entation of vocal
fold !o#ilit% should #e a routine part of the preoperative ph%sical e5a!ination of an% patient presenting $ith a
th%roid !ass: ostoperative visuali>ation should also #e perfor!ed, as these patients !a% #e as%!pto!atic,
especiall% at first:
Lar%ngeal electro!%ograph% ,E+1- !a% #e useful to distinguish vocal fold paral%sis fro! in=ur% to the
cricoar%tenoid =oint secondar% to intu#ation: 3urther!ore, E+1 !a% %ield infor!ation concerning the prognosis of
the patient $ith *LN in=ur%:
arnes et al ,6A7B- perfor!ed lar%ngeal E+1 in 28 patients $ith vocal fold paral%sis due to nu!erous etiologies
,eg, idiopathic causes, surger%, tu!or, trau!a, neurologic diseases-:
?
No patient in $ho! E+1 revealed
an a#sence of !otor unit potentials or fi#rillation potentials regained !ove!ent of the true vocal fold: &f 68
patients $ho had nor!al or pol%phasic action potentials, 66 regained function: (o$ever, !ost of the tests $ere
perfor!ed !ore than C !onths after the onset of paral%sis/ therefore, this stud% revealed little regarding the
usefulness of earl% E+1 testing:
The patient $ith #ilateral paral%sis of the true vocal folds $ho presents $ith air$a% o#struction after e5tu#ation
li)el% re;uires e!ergenc% reintu#ation or tracheoto!%: 3i#eroptic lar%ngoscop% !a% #e perfor!ed to confir! the
diagnosis if the patient is clinicall% sta#le:
"re*ention
.eli#erate identification of the *LN !ini!i>es the ris) of in=ur%: 2hen the nerve is identified and dissected, the
reported *LN in=ur% rate during th%roidecto!% is 0'2:69: This rate is reportedl% higher if surger% is repeated ,2'
629- or if the nerve is not clearl% identified ,8'C:C9-: 0ntraoperative he!ostasis and a thorough understanding of
the anato!% are essential for identif%ing and preserving the nerve:
The course of the *LN differs on the right and left sides of the nec) ,see 0!age 6-: The left *LN #ranches fro! the
vagus at the level of the aortic arch: 0t then passes #elo$ the arch and reverses its course to continue superiorl%,
posterior to the aortic arch and into the visceral co!part!ent of the nec): 0t travels near or in the tracheoesophageal
groove until it enters the lar%n5 =ust #ehind the cricoth%roid articulation: The right *LN #ranches fro! the vagus
!ore superiorl% than does the left, at the level of the su#clavian arter%: 0t loops #ehind the right su#clavian arter%
and ascends supero!ediall% to$ard the tracheoesophageal groove: 0t then continues superiorl% until entering the
lar%n5 #ehind the cricoth%roid articulation:
Classic descriptions of the *LNs hold that the% ascend in the tracheoesophageal groove/ ho$ever, the% !a% in fact
#e lateral to it: Lo$ in the nec), the course of the right *LN is relativel% o#li;ue and lateral and, pro#a#l%, !ore
prone to in=ur% than the left *LN: The nerve !a% #ranch several ti!es #efore entering the lar%n5: Ta)e care to
identif% and preserve each #ranch:
0n appro5i!atel% B of 6000 patients, a nonrecurrent lar%ngeal nerve is found on the right side: This arrange!ent
occurs $hen a retroesophageal right su#clavian arter% arises fro! the dorsal side of the aortic arch: The
nonrecurrent lar%ngeal nerve #ranches fro! the vagus at appro5i!atel% the level of the cricoid cartilage and
directl% enters the lar%n5 $ithout looping around the su#clavian arter%: A left'sided nonrecurrent lar%ngeal nerve
*LN can occur onl% $hen a right'sided aortic arch and liga!entu! arteriosu! are concurrent $ith a left
retroesophageal su#clavian arter%:
The inferior th%roid arter% has #een descri#ed as an i!portant land!ar) for identif%ing the *LN: (o$ever, its
relationship to the nerve is su#=ect to variation ,see 0!age 2-: Nu!erous descriptions and atte!pts to ;uantif% the
percentages of each relationship of the nerve to the arter% have #een put forth: ercentages differ on the right and
left sides: &n the right, the nerve runs #et$een #ranches of the arter% in appro5i!atel% B09 of patients: The nerve
is anterior to the arter% in 2B9 and posterior in 2B9: &n the left, the nerve courses posteriorl% to the arter% in B09
of patients/ in appro5i!atel% ?B9, the nerve runs #et$een #ranches: 0n onl% 6B9 is it anterior to the arter%: 0n
su!!ar%, the nerve is al$a%s near the arter%, #ut the e5act relationship cannot #e deter!ined $ith certaint%:
Therefore, the inferior th%roid arter% is not a dependa#le land!ar) for identif%ing the nerve:
Several approaches are used to identif% and preserve the *LN: The authors4 preferred approach involves finding the
nerve at its point of lar%ngeal entr%, $hich is appro5i!atel% 0:B c! #elo$ the inferior cornu of the th%roid cartilage:
Th%roid tissue in the region of the liga!ent of <err% is !eticulousl% dissected fro! the trachea #% carefull% ligating
traversing vessels: This techni;ue e5poses the *LN as it enters the lar%n5: 0t also !ini!i>es the co!pro!ise of
#lood suppl% to the parath%roids and li!its the e5tent of dissection involving the nerve:
Thic) connective tissue called the <err% liga!ent attaches the th%roid to the trachea at the level of the second or
third tracheal ring: This is the !ost co!!on site of in=ur% to the *LN The nerve !a% run deep to the liga!ent, pass
through it, or even penetrate the gland a short distance at this level: <e e5tre!el% careful in this area during surger%:
*etraction of the th%roid lo#e !a% result in traction in=ur% and !a)e the nerve suscepti#le to transection: The path
of the nerve !ust #e clearl% identified:
Continuous electroph%siologic !onitoring of the *LN during th%roid surger% is easil% perfor!ed: T$o E+1
devices include an endotracheal'tu#e electrode ,Do!ed'Treace, Eac)sonville, 3L- and an *LN'postcricoid'
lar%ngeal surface electrode: <oth provide useful E+1 infor!ation and help to reveal the location of the *LN:
Use of E+1 is controversial and has not #een reco!!ended for routine th%roid surger% given the lo$ rate of *LN
in=ur%: The authors )no$ of no rando!i>ed studies that have #een perfor!ed to co!pare the rate of postoperative
*LN pals% in visual versus electroph%siologic *LN detection in th%roid surger%: The additional infor!ation E+1
provides !a% #e #eneficial in patients undergoing revision th%roid surger%, in patients $ith previousl% radiated
nec)s, in patients $ith large !asses, or in patients $ith contralateral nerve pals%:
0n the setting of unilateral vocal'fold paral%sis, !anage!ent of the contralateral th%roid is controversial: 0n the
authors4 e5perience, given the lo$ rate of *LN in=ur%, the #est approach is not changing appropriate oncologic
!anage!ent and proceeding $ith total th%roidecto!%: E5ceptions !a% include a %oung patient $ho presents $ith a
lo$ ,FC- !ultifactor activated i!!une cell ,+A0C- score: 3or such a patient, nonoperative treat!ent !a% #e
considered, $ith appropriate care coordinated $ith an endocrinologist:
Treatment
.o not perfor! corrective procedures for unilateral vocal'fold paral%sis until at least C !onths after th%roidecto!%
#ecause a reversi#le in=ur% i!proves #% that ti!e: 0f the nerve $as definitel% transected during surger%, treat!ent
for the paral%>ed fold !a% #e perfor!ed sooner than this:
T$o surgical treat!ent options are availa#le for patients $ith unilateral vocal'fold paral%sis: !ediali>ation and
reinnervation: +ediali>ation is !ost co!!onl% perfor!ed: (o$ever, the authors4 )no$ledge, no investigator has
co!pared the efficac% of these 2 procedures:
+ediali>ation of the i!paired vocal fold i!proves contact $ith the contralateral !o#ile fold: 0t !a% #e
acco!plished $ith in=ection lar%ngoplast% or lar%ngeal fra!e$or) surger%: T%pe 0 th%roplast% is pro#a#l% the !ost
co!!on procedure: A $indo$ in the th%roid cartilage is created at the level of the true vocal fold: An i!plant is
then placed to push the vocal fold !ediall%: +ediali>ation $ith an in=ection of a#sor#a#le gelatin sponge ,1elfoa!/
har!acia G Up=ohn Co!pan%, "ala!a>oo, +0- !a% #e perfor!ed #efore C !onths if the patient desires it or if he
or she has is aspirating: The gelatin sponge resor#s over ti!e and is, therefore, a te!porar% treat!ent:
An i!plant !ade of silicone or pol%tetrafluoroeth%lene ,T3E, 1ore'Te5/ 2: L: 1ore G Associates, 0nc/ Ne$ar),
.E- is considered per!anent: (o$ever, !ost authorities agree that no negative conse;uences occur if nerve
recovers function after a t%pe 0 th%roplast%: 0n addition, the i!plant !a% #e re!oved, though this re;uires another
surgical procedure:
A nu!#er of reinnervation procedures have #een descri#ed for addressing the per!anentl% in=ured *LN: These
procedures !aintain or restore tone to the intrinsic lar%ngeal !usculature: 2hen the true vocal fold atrophies after
denervation, it loses contact $ith the contralateral fold and the voice $ea)ens: <% preventing atroph%, reinnervation
procedures !a% help !aintain or i!prove the patient4s voice:
ri!ar% neurorrhaph% !a% #e used to i!!ediatel% repair the transected *LN: This procedure t%picall% results in
s%n)inesis #ecause of nonselective reinnervation of a#ductor and adductor !uscles: *einnervation procedures have
#een descri#ed #% using the phrenic nerve, ansa cervicalis, and preganglionic s%!pathetic neurons: Although
ani!al !odels de!onstrated E+1 and histologic evidence of reinnervation, as $ell as restored !ove!ent of the
vocal fold, e5perience in hu!ans has not #een as i!pressive as this: 0!prove!ent in phonation ;ualit% has #een
docu!ented in hu!ans after reinnervation $ith the ansa cervicalis, #ut no !ove!ent is o#served: Transfer of
neuro!uscular pedicles have #een descri#ed and reportedl% restore !ove!ent of the vocal fold: (o$ever, these
reports are li!ited, and success is not universal:
0n #ilateral vocal'cord paral%sis, initial treat!ent involves o#taining an ade;uate air$a%: E!ergenc% tracheoto!%
!a% #e re;uired: 0f possi#le, first perfor! endotracheal intu#ation: Consider e5ploring the nec) to ensure that no
reversi#le causes of nerve in=ur% ,eg, !isplaced ligature- are present: 2hen good preservation of the *LNs is
ascertained, a trial of e5tu#ation !a% #e perfor!ed after several da%s: 0ntravenous steroids !a% #e #eneficial in this
situation: *e!ove the tu#e over a Coo) catheter and in a controlled setting in case reintu#ation is necessar%: <e
read% to perfor! e!ergent tracheoto!%: 0f nerve function has not recovered after a second trial of e5tu#ation,
tracheoto!% is certainl% $arranted:
The principal goal for surger% in #ilateral vocal'fold paral%sis is to i!prove air$a% patenc%: Cordoto!% and
ar%tenoidecto!% are the !ost co!!on procedures: These procedures enlarge the air$a% and !a% per!it
decannulation of a tracheosto!%: (o$ever, the patient !ust #e counseled that his or her voice $ill li)el% $orsen
after surger%: Transfer of a neuro!uscular pedicle is reported to i!prove the air$a% in cases of #ilateral true vocal'
fold paral%sis: (o$ever, again, these reports are li!ited, and this treat!ent is not a $idel% accepted:
H1"O"ARATH1ROIDIS!
(%poparath%roidis! is another feared co!plication of th%roid surger%: The parath%roid glands produce parath%roid
hor!one ,T(-, $hich is inti!atel% involved in the regulation of seru! calciu!: T( increases seru! calciu!
levels #% causing #one resorption, increasing renal a#sorption of calciu!, and sti!ulating the s%nthesis of the
#iologicall% active for! of vita!in . ,6,2B'dih%dro5% vita!in .-: 6,2B'.ih%dro5% vita!in . increases seru!
calciu! levels #% !eans of a nu!#er of !echanis!s, including increasing the intestinal a#sorption of calciu!:
T( also increases renal e5cretion of phosphorous: Therefore, lo$ T( levels result in high seru! phosphorous
levels:
0nade;uate production of T( leads to h%pocalce!ia: (%poparath%roidis!, and the resulting h%pocalce!ia, !a% #e
per!anent or transient: The rate of per!anent h%poparath%roidis! is 0:8'6?:79: The condition !a% #e due to direct
trau!a to the parath%roid glands, devasculari>ation of the glands, or re!oval of the glands during surger%:
The rate of te!porar% h%pocalce!ia is reportedl% 2'B?9: The cause of transient h%pocalce!ia after surger% is not
clearl% understood: 0t !a% #e attri#uta#le to te!porar% h%poparath%roidis! caused #% reversi#le ische!ia to the
parath%roid glands, h%pother!ia to the glands, or release of endothelin'6: Endothelin'6 is an acute'phase reactant
)no$n to suppress T( production, and levels have #een elevated in patients $ith transient h%poparath%roidis!:
&ther h%potheses have #een put forth to account for transient h%pocalce!ia not caused #% h%poparath%roidis!:
These include calcitonin release and hungr%'#one s%ndro!e: Calcitonin is produced #% the th%roid and inhi#its
#one #rea)do$n $hile sti!ulating renal e5cretion of calciu!: 0ts effects on calciu! !eta#olis! oppose those of
T(: (ungr%'#one s%ndro!e occurs in patients $ith preoperative h%perth%roidis!: These patients have increased
#one #rea)do$n in their h%perth%roid state: 2hen a patient4s th%roid hor!one level drops acutel% after surger%, his
or her sti!ulus to #rea) do$n #one is re!oved: The #ones, no$ Hhungr%H for calciu!, re!ove calciu! fro! the
plas!a, decreasing seru! calciu! levels:
*is) factors for h%pocalce!ia after th%roidecto!% include 1raves disease and !alignanc%: The t%pe of procedure
perfor!ed ,total th%roidecto!%, th%roidecto!% $ith nec) dissection, repeat th%roidecto!%, su#total th%roidecto!%,
near'total th%roidecto!%- also affects the ris) in transient h%pocalce!ia after surger%: As !ore of the parath%roid
gland inadvertentl% re!oved, the ris) of h%pocalce!ia rises:
"resentation
+ost patients $ho are h%pocalce!ic after th%roidecto!% are initiall% as%!pto!atic: S%!pto!s and signs of
h%pocalce!ia include circu!oral paresthesias, !ental status changes, tetan%, carpopedal spas!, lar%ngospas!,
sei>ures, IT prolongation on EC1, and cardiac arrest:
E*aluation
Evaluate ioni>ed calciu! ,or total calciu! and al#u!in- levels in the perioperative period in patients undergoing
total th%roidecto!%: 0f iatrogenic h%poparath%roidis! is a concern, close follo$'up care is $arranted for at least 72
hours or until calciu! levels de!onstrate that parath%roid function is intact:
The Chvoste) sign and the Trousseau sign !a% #e elicited at #edside in the setting of h%pocalce!ia: The Chvoste)
sign is elicited #% tapping the facial nerve in the preauricular area and o#serving for facial contractions: The
Trousseau sign is o#served #% inducing carpal spas! upon inflation of a #lood pressure cuff:
0n the setting of h%pocalce!ia, other causes ,renal failure, h%po!agnese!ia, !edications- !a% #e considered:
(o$ever, routine !onitoring of T( levels after surger% is not reco!!ended #ecause surgical !anipulation of the
parath%roids !a% transientl% alter the!: Seru! phosphorous levels are elevated in patients $ith
h%poparath%roidis! secondar% to decreased renal e5cretion/ this difference !a% help in distinguish lo$ T(
levels due to other etiologies of h%pocalce!ia ,eg, hungr% #one s%ndro!e-: *egardless of the etiolog%, the
!anage!ent is unchanged: 0f uncertaint% re!ains C !onths after surger%, T( levels !a% #e chec)ed to confir!
the cause of h%pocalce!ia and to identif% recover% of parath%roid gland function:
"re*ention
The #est $a% to preserve parath%roid gland function is to identif% the glands and to !aintain their #lood suppl%: A
large cadaveric stud% to identif% the !ost co!!on positions of the parath%roid glands de!onstrated that 779 of
superior parath%roid glands $ere at the cricoth%roid =unction and inti!atel% associated $ith the *LN: A#out
229 of the superior parath%roid glands $ere on the posterior surface of the upper lo#e of the th%roid:
Appro5i!atel% 69 of the superior glands $ere #ehind the =unction of the h%pophar%n5 and upper esophagus:
The stud% de!onstrated that the location of the inferior parath%roid glands $as varia#le: 3ort%'t$o percent $ere on
the anterior or lateral surfaces of the lo$er lo#e of the th%roid, often hidden #% vessels or creases in the th%roid:
Thirt%'nine percent $ere located $ithin the superior tongue of the th%!us: 3ifteen percent $ere e5trath%roidal and
lateral to the lo$er lo#e: T$o percent $ere in the !ediastinal th%!us, and another 29 $ere in other ectopic
positions, such as the carotid sheath: The ectopic inferior parath%roid glands $ere consistentl% associated $ith
re!nant th%!us tissue:
The inferior parath%roid glands and the th%!us #oth develop fro! the third #ranchial pouch, a finding that e5plains
the close association of these structures: The inferior parath%roid glands receive their #lood suppl% fro! the inferior
th%roid arter%: The superior parath%roids also usuall% receive their #lood suppl% fro! the inferior th%roid arter%:
(o$ever, in so!e cases, the superior parath%roids receive their vascular suppl% fro! the superior th%roid arter%, the
anasto!otic loop #et$een the inferior and superior th%roid arteries, or direct #ranches off the th%roid gland:
The )e%s to parath%roid preservation are identif%ing the parath%roids and preserving their #lood suppl% #% ligating
all vessels distal to the!: Ligate vessels as close to the th%roid gland as possi#le: *ecognition of the parath%roid
glands, $hich appear in various shapes and $hich have a cara!el'li)e color, is critical: 2hen the% lose their #lood
suppl%, the% turn #lac):
The devasculari>ed gland ,pathologicall% confir!ed $ith fro>en'section anal%sis-, should #e re!oved, cut into 6' to
2'!! pieces, and rei!planted in the sternocleido!astoid !uscle or the forear!: The location should #e !ar)ed
$ith a per!anent suture or a clip applier ,Ligaclip/ Ethicon 0nc, So!erville, NE-: So!eti!es, the inferior glands are
so anterior that preserving their #lood suppl% is difficult: 0n this case, the glands should #e rei!planted as $ell:
&nce re!oved, e5a!ine the th%roid gland: An% parath%roid glands in e5cised th%roid tissue are then rei!planted:
Treatment
atients $ho have as%!pto!atic h%pocalce!ia in the earl% postoperative period should not #e treated $ith
supple!ental calciu!: Authorities #elieve that the h%pocalce!ic state sti!ulates the stunned parath%roid glands to
produce T(:
atients $ho have s%!pto!atic h%pocalce!ia in the earl% postoperative period or $hose calciu! levels continue to
fall re;uire treat!ent: 0n s%!pto!atic patients, replace calciu! $ith intravenous calciu! gluconate: Ten !illiliters
of 609 solution ,6 g- !a% #e ad!inistered over 60 !inutes: A calciu! infusion !a% #e started at a rate of 6'2
!g@)g@h if s%!pto!s do not resolve: Titrate the infusion to the patient4s s%!pto!s and calciu! levels: Start oral
calciu! $hen the patient is a#le to tolerate it: &ne to t$o gra!s of ele!ental oral calciu! should #e supplied each
da%: Calciu! car#onate 62B0 !g provides B00 !g of ele!ental calciu!/ therefore, the patient should ta)e 2B00'
B000 !g@da%: The patient needs conco!itant replace!ent of vita!in . $ith calcitriol ,*ocaltrol- 0:2B'6 !cg@d:
The authors reco!!end assistance fro! an endocrinologist to ensure close !onitoring of calciu! levels and to
!edicall% !anage the se;uelae of h%poparath%roidis!: 0n 6'2 !onths, an atte!pt to $ean the patient off oral
calciu! !a% #e !ade to reveal if the h%poparath%roidis! is te!porar%: .ependence on calciu! supple!entation
for longer than C !onths pro#a#l% indicates per!anent h%poparath%roidis!:
TH1ROTO3IC STOR!
Th%roto5ic stor! is an unusual co!plication of th%roid surger%: This condition !a% result fro! !anipulation of the
th%roid gland during surger% in the patients $ith h%perth%roidis!: 0t can develop preoperativel%, intraoperativel%, or
postoperativel%: Surger% is generall% reco!!ended onl% $hen patients have 1raves disease and other treat!ent
strategies fail or $hen underl%ing th%roid cancer is suspected: Th%roto5ic stor! is potentiall% lethal and !ust #e
dealt $ith astutel%:
"resentation and e*aluation
Signs of th%roto5ic stor! in the anestheti>ed patient include evidence of increased s%!pathetic output, such as
tach%cardia and h%perther!ia: &ther s%!pto!s and signs in the a$a)e patient include nausea, tre!or, and altered
!ental status: Cardiac arrh%th!ias !a% also occur: 0f treat!ent is not given, the patient !a% progress to co!a:
"re*ention
reoperative a$areness of the h%perth%roid patient and appropriate !edical treat!ent are the )e%s preventing
th%roto5ic stor!: atients undergoing th%roidecto!% for persistent th%roto5icosis re;uire treat!ent #ased on the
ti!e availa#le and the severit% of s%!pto!s: The goal is to restore a state as close to euth%roid as possi#le #efore
surger%: +edical !anage!ent is directed at targets of the th%roid hor!one s%nthetic, secretor%, and peripheral
path$a%s: These include thioa!ides ,!ethi!a>ole, prop%lthiouracil JTUK-, $hich affect s%nthesis:
TU also inhi#its peripheral deiodination ,th%ro5ine JT8K to triiodoth%ronine JT?K-: 0odine used at supraph%siologic
doses decreases s%nthesis of ne$ th%roid hor!one ,the 2olff'Chai)ov effect-, and it has an onset of action $ithin
28 hours and a !a5i!u! effect at 60 da%s: <eta'#loc)ers should #e given to ever% th%roto5ic patient unless
contraindicated ,eg, congestive heart failure JC(3K-: (igh doses of glucocorticosteroids i!pair peripheral
conversion of T8 to T? and are used for $hen th%roto5icosis is severe and $hen rapid !anage!ent is necessar%:
+or#idit% and !ortalit% rates in ade;uatel% prepared patient are lo$:
Intraoperati*e management
The first step in !anaging a th%roto5ic crisis during th%roidecto!% is to stop the procedure: 0ntravenous #eta'
#loc)ers, TU, sodiu! iodine, and steroids are ad!inistered to control s%!pathetic activit%, the release of th%roid
hor!one, and h%perther!ia: Use cooling #lan)ets and cooled intravenous fluids to reduce the patient4s #od%
te!perature: Carefull% !onitor o5%genation, #ecause o5%gen de!ands increase dra!aticall% during a th%roid
stor!:
"ostoperati*e management
*e!oval of the th%roid gland does not i!!ediatel% relieve th%roto5icosis #ecause the half'life of circulating T8 is
7'7 da%s: As th%roid hor!one levels decrease and as s%!pto!s resolve, !edications should #e graduall% $eaned
over the $ee)s after surger%: An endocrinologist should #e consulted to assist in this process:
IN&UR1 TO THE SU"ERIOR %AR1N0EA% NER2E
The SLN has 2 divisions: internal and e5ternal: The internal #ranch provides sensor% innervation to the lar%n5: 0t
enters the lar%n5 through the th%roh%oid !e!#rane and, therefore, should not #e at ris) during th%roidecto!%: The
e5ternal #ranch provides !otor function to the cricoth%roid !uscle and is at ris) during th%roidecto!%: This !uscle
is involved in elongation of the vocal folds: Trau!a to the nerve results in an ina#ilit% to lengthen a vocal fold and,
thus, an ina#ilit% to create a high'pitched sound:
The e5ternal #ranch of the SLN is pro#a#l% the nerve !ost co!!onl% in=ured in th%roid surger%: The rate of in=ur%
to the e5ternal #ranch of the SLN is esti!ated at 0'2B9: This rate is pro#a#l% underesti!ated, #ecause the
diagnosis is fre;uentl% !issed:
"resentation
The clinical presentation of a patient $ith SLN paral%sis !a% #e su#tle: +ost patients do not notice an% change: &n
occasion, a patient presents $ith !ild hoarseness or decreased vocal sta!ina: (o$ever, for the singer or person
$ho professionall% relies on his or her voice, paral%sis of the SLN !a% #e threaten his or her career: The !ost
da!aging conse;uence is loss of the upper register:
E*aluation
.iagnosing an SLN in=ur% $ith indirect or fi#eroptic lar%ngoscop% is difficult: osterior glottic rotation to$ard the
paretic side and #o$ing of the vocal fold on the $ea) side !a% #e noted: 0n addition, the affected vocal fold !a% #e
lo$er than the nor!al vocal fold:
Use of videostro#oscop% and lar%ngeal E+1 has enhanced the a#ilit% of otolar%ngologists and speech pathologists
to diagnose SLN paral%sis: Lideostro#oscop% de!onstrates an as%!!etric, !ucosal traveling $ave: E+1
de!onstrates cricoth%roid !uscle denervation:
"re*ention
The e5ternal SLN #ranch travels inferiorl% along the lateral surface of the inferior constrictor until it ter!inates at
the cricoth%roid !uscle: This #ranch is inti!atel% related to the superior th%roid arter%, though its e5act relation to
the arter% varies:
.ata fro! a recent cadaveric stud% suggested that the nerve !a% cross the superior th%roid arter% M6 c! a#ove the
upper pole of the th%roid gland ,829-, F6 c! a#ove the upper pole ,?09-, or under the upper pole ,689-: 0n so!e
people, the nerve runs dorsal to the arter% and crosses onl% its ter!inal #ranches after the arter% has ra!ified ,689-:
A critical area 6:B'2 c! fro! the th%roid capsule is descri#ed: 0n this area, the e5ternal #ranch of the SLN is !ost
inti!atel% involved $ith the #ranches of the superior th%roid arter%:
+ost surgeons agree that identif%ing the SLN, in contrast to the *LN, is unnecessar%: 0nstead, ligate the ter!inal
#ranches of the superior th%roid arter% as close to the th%roid capsule as possi#le to avoid da!aging the nerve:
Electroph%siologic !onitoring of the SLN is descri#ed, #ut it is not reco!!ended for routine use:
.irect trau!a to the cricoth%roid !uscle can cause fi#rosis and poor !uscle function, $hich !a% result in a
presentation si!ilar to that of a patient $ith an in=ur% to the e5ternal #ranch of the SLN, even $hen the nerve is
preserved: Therefore, dissect carefull% near this !uscle and avoid electrocauter% da!age $hen possi#le:
Treatment
At present, the onl% treat!ent availa#le for in=ur% to the e5ternal #ranch of the SLN is speech therap%:
INECTION
0nfection $as the !a=or cause of death fro! th%roid surger% during the 6700s: Toda%, infection occurs in less than
6'29 of all cases: .eath is unli)el% if the infection is recogni>ed and treated pro!ptl% and appropriatel%:
"resentation
ostth%roidecto!% infection !a% !anifest as superficial cellulitis or as an a#scess: atients $ith cellulitis t%picall%
present $ith er%the!a, $ar!th, and tenderness of nec) s)in around the incision: A superficial a#scess !a% #e
diagnosed on the #asis of fluctuance and tenderness: A deep nec) a#scess !a% !anifest su#tl%, #ut signs such as
fever, pain, leu)oc%tosis, and tach%cardia should raise clinical suspicion:
E*aluation
Send purulence e5pressed fro! the $ound or drained fro! an a#scess for 1ra! staining and culturing to direct the
choice of anti#iotics: CT i!aging is useful $hen a deep nec) a#scess is thought possi#le: 0n addition, a deep nec)
a#scess should raise concern a#out possi#le esophageal perforation: An esophageal s$allo$ stud% perfor!ed $ith
sodiu! a!idotri>oate and !eglu!ine a!idotri>oate solution ,1astrografin- !a% #e useful in certain cases:
"re*ention
The )e% to preventing postoperative infection is the use of sterile surgical techni;ue: *outine use of perioperative
anti#iotics in th%roid surger% has not #een proven #eneficial:
Eohnson and 2agner ,6A77- retrospectivel% revie$ed 8?7 patients $ho under$ent unconta!inated head and nec)
surger% at the E%e and Ear (ospital of itts#urgh: &f 66? patients $ho received th%roidecto!%, onl% 62 $ere
given anti#iotics perioperativel%: None of the th%roidecto!%'treated patients had a postoperative $ound infection:
This result suggests that perioperative anti#iotics are not useful: Anti#iotics should not #e used unnecessaril% in the
current era of !ultidrug'resistant #acteria: erioperative anti#iotics are not reco!!ended for th%roid surger%:
Treatment
Treat cellulitis $ith anti#iotics that provide good coverage against gra!'positive organis!s ,eg, against
staph%lococci and streptococci-: .rain a#scesses, and direct anti#iotic coverage according to culture findings: 0f
patients have deep nec) a#scesses, #egin $ith #road'spectru! anti#iotics ,eg, cefuro5i!e, clinda!%cin, a!picillin'
sul#acta!- until definitive culture results are availa#le:
(N&T(N*&0.0S+
"resentation
Untreated h%poth%roidis! causes s%!pto!s such as cold intolerance, fatigue, constipation, !uscle cra!ping, and
$eight gain: (%poth%roidis! secondar% to th%roid surger% should never #e left untreated long enough to elicit signs
and s%!pto!s of !%5ede!a ,eg, hair loss, large tongue, cardio!egal%-: E5pect, diagnose, and pro!ptl% treat
postoperative h%poth%roidis!:
E*aluation
The !ost useful la#orator% test for detecting or !onitoring of h%poth%roidis! in the patient $ho has undergone
th%roidecto!% is the !easure!ent of th%rotropin ,th%roid'sti!ulating hor!one JTS(K- levels: Total T8 and T?
levels !a% #e useful to fine'tune the dosing of levoth%ro5ine ,S%nthroid-, #ut !a% #e unhelpful in the t%pical
postoperative patient:
"re*ention
(%poth%roidis! is an e5pected se;uela of total th%roidecto!%: 0n goiter surger%, the e5tent of th%roidecto!% is
controversial: The !ain goal of surger% is to prevent recurrent h%perth%roidis! #ecause recurrent h%perth%roidis!
after surger% is !ore difficult than per!anent h%poth%roidis! to !anage: <ecause of this fact, the present authors
reco!!end total th%roidecto!% in this setting:
Treatment
3or h%poth%roid patients, start levoth%ro5ine ,a#out 6:7 !cg@)g@d-: Chec) their th%rotropin level in appro5i!atel%
8'C $ee)s, and ad=ust the dosage appropriatel%: atients $ho are to receive postoperative radioiodine scanning !ust
stop ta)ing levoth%ro5ine #efore the procedure: Consider assistance fro! an endocrinologist during this period to
ensure appropriate !onitoring ,eg, of renal insufficienc% due to h%poth%roidis!-:
!inimally in*asi*e *ideo4assisted thyroidectomy
The develop!ent of videolaparoscopic surger% in the last decade has allo$ed several operations to #e perfor!ed
$ith !ini!all% invasive techni;ues: After the first parath%roidecto!% procedure $as perfor!ed endoscopicall% in
6AAC, this !ini!all% invasive approach $as applied to th%roid surger%:
+ini!all% invasive video'assisted th%roidecto!% ,+0LAT- $as first used in 6AA7: The techni;ue is characteri>ed
#% uni;ue central access $ith a 6:B'c! incision and e5ternal retraction: Lideo'assisted th%roidecto!% $as tested
successfull% in ani!als and has #een perfor!ed safel% in hu!an patients: ostoperative !or#idit% rates in patients
have see!ed to #e e;uivalent to those of patients $ho have undergone conventional surger%:
Chao et al ,2008- prospective co!pared video'assisted th%roid lo#ecto!% and conventional lo#ecto!% in 66C
patients $ith th%roid nodules:
8
No deaths, he!ato!as, $ound infections, cases of h%poth%roidis!, or *LN palsies
$ere reported: .a!age to the SLN occurred in C ,60:29- patients after conventional surger% and in no patients in
the video'assisted group: Transient *LN pals% occurred in B ,7:B9- patients $ho under$ent conventional surger%
versus ? ,B:79- patients in the video'assisted group/ the difference $as not significant: atients in #oth groups $ere
discharged ho!e on the second postoperative da%:
0n a B'%ear stud%, +iccoli et al ,2008- selected B7A patients to undergo +0LAT:
B
The operation consisted of total
th%roidecto!% in ?62 patients and lo#ecto!% in 2C7: The !ean operative ti!es $ere 86 !inutes ,range, 6B'620
!in- for lo#ecto!% and B6:C !inutes ,range, ?0'680 !in- for total th%roidecto!%: The postoperative hospital sta%
$as 28 hours ,overnight discharge- for all patients: Co!plications included postoperative #leeding ,0:69-,
recurrent nerve pals% ,6:?9-, and definitive h%poparath%roidis! ,0:29-:
+0LAT provides endoscopic !agnification of nerves and vessels and !a% help i!prove aesthetic results: (o$ever,
the cos!etic result o#tained $ith an appropriatel% si>ed and placed conventional incision is also good: The
endoscopic techni;ue cannot #e used in nodules M?B !! or in goiters #ecause the speci!en is too large to retrieve
through the 6:B'c! port incision: 0n addition, this techni;ue is not ideal for re!oving carcino!as $here an intact
capsule is necessar% for histologic assess!ent:
0n su!!ar%, if the general principals of conventional th%roid surger% are follo$ed, video assistance !a% help in
identif%ing structures and in !ini!i>ing the incision: E5perienced surgeons !a% consider using this techni;ue
$hen the e;uip!ent is availa#le/ $hen patients have s!all follicular nodules, adeno!as, or $ell'differentiated
papillar% cancer/ and $hen proph%lactic th%roidecto!% is #eing perfor!ed in patients $ith ret protooncogene
!utations:
!U%TI!EDIa
+edia file 6: Anatomy of the recurrent laryngeal ner*e +R%N,5
Lie$ 3ull Si>e 0!age
+edia t%pe: 0llustration
+edia file 2: Relationship of the recurrent laryngeal ner*e +R%N, to the left and right
inferior thyroid arteries5
Lie$ 3ull Si>e 0!age
+edia t%pe: 0llustration
+edia file ?: Nonrecurrent laryngeal ner*e5
Lie$ 3ull Si>e 0!age
+edia t%pe: 0llustration
+edia file 8: Inferior parathyroids5
Lie$ 3ull Si>e 0!age
+edia t%pe: 0llustration
+edia file B: Superior parathyroids5
Lie$ 3ull Si>e 0!age
+edia t%pe: 0llustration
+edia file C: Superior laryngeal ner*e +S%N,5